Correlates of physical activity among First Nations children residing in First Nations communities in Canada.

Janssen, Ian ; Levesque, Lucie ; Xu, Fei 等

Recent estimates, which are based on objective measures of physical activity from the 2007-2009 Canadian Health Measures Survey, indicate that only one in ten school-aged children in Canada meet the current public health guideline of 60 minutes per day of moderate-to-vigorous physical activity (MVPA). (1) While little is known about the physical activity levels of Aboriginal children, (2) including the First Nations population, the data that are available suggest that inactivity in these groups is a concern. For instance, a recent study of self-reported MVPA from 204 on-reserve 10-16 year olds found that only 14% of boys and 4% of girls met public health guidelines for MVPA. (3)

Numerous mental, emotional, spiritual and physical problems in First Nations peoples may be related to an inactive lifestyle. (4-6) A lack of physical activity in First Nations children is of particular concern as they are disproportionately disadvantaged economically and socially through poverty, inadequate housing and low educational achievement. (7) Children deprived of opportunities for participation in physical activity are not only at higher risk for negative physical and psychosocial outcomes, but are also being denied the prospect to become fully enabled for life (8) and to live in balance. (5)

In order to develop evidence-based interventions to foster positive physical activity habits in First Nations children, it is necessary to understand the factors that influence physical activity behaviour. (9) Behaviour theories and models provide a systematic framework for examining the factors that influence a behaviour such as MVPA. (10) Ecological models are commonly used in the physical activity literature. (10,11) These ecological models postulate that physical activity is influenced by factors at multiple levels, including intrapersonal (e.g., age, gender, cultural beliefs), interpersonal (e.g., relationships and characteristics of family) and community levels (e.g., social and economic conditions, facilities and programs). (12) There is a lack of research on the determinants of physical activity among First Nations children who reside in First Nations communities.

The purpose of the current study was to examine independent associations between intrapersonal factors, family factors and community factors with physical activity among First Nations school-aged children residing in First Nations communities. These associations were assessed in the 2008/10 First Nations Regional Health Survey (RHS), a nationally representative sample of First Nations persons who reside in on-reserve and northern First Nations communities across Canada.

METHODS

Survey and participants

A detailed description of the RHS can be found elsewhere. (13) Briefly, the RHS addresses a holistic range of priority health issues for First Nations. It was overseen by the First Nations Information Governance Centre (FNIGC). The questionnaires were completed between 2008 and 2010 via in-person interviews using a Computer Assisted Personal Interview (CAPI) system administered by local field workers. A primary caregiver completed the questionnaire (~22 minutes) for child participants.

A total of 3,184 children aged 6-11 years were included in the RHS. The total population represented in the final MVPA analysis was 43,605 persons, which accounted for 89% of 6-11 year old First Nations children living in on-reserve and northern First Nations communities. The corresponding numbers for the traditional activities analysis were 45,116 and 92% respectively. The RHS was designed to represent the First Nations population living in First Nations communities (e.g., on-reserve and in northern Canada above the 60th parallel) in all provinces and territories, except Nunavut. Overall, 216 communities were included and 5.3% of the target population was surveyed. The response rate was 72.5%.

The RHS sample design incorporated a two-stage sampling strategy. The first stage involved the selection of communities to participate in the survey. Initially, all First Nations communities in Canada were stratified by region, subregion and community size [large (1,500+ people), medium (300-1,499 people) and small (<300 people)]. Large communities were automatically included, while medium and small communities were randomly selected with equal probability within their respective strata. When a randomly selected community chose not to participate, it was replaced randomly with another community in the same subregion and size grouping.

The second stage of sampling pertained to the selection of individuals within participating communities. All community members were identified using band membership lists. Community members were randomly selected within age/gender groups from these lists. When a selected community member chose not to participate, a substitution was made from the ordered randomly generated list. The sampling rate within each community was determined as a function of the overall subregion probability (within regions) and the probability of selection of the community (within subregion). Individual responses were weighted, using Indian and North American Affairs Canada registry counts, to reflect the representation of the population by the sample.

Intrapersonal factors

Demographics: Gender and age categories were considered. The mid-point of the age range defined the two age categories (6-8 and 9-11 years). Age was categorized to be consistent with the categorical nature of the remaining correlates.

First Nations Language: Use of First Nations language was grouped as follows: 'does not understand/speak a First Nations language', 'understands/speaks a First Nations language but does not use most often in daily life' and 'use of a First Nations language most often in daily life'.

First Nations Culture: Importance of First Nations culture was assessed by asking "How important are traditional cultural events in your child's life?" Response options were 'very important', 'somewhat important', 'not very important' and 'not important'.

School Attendance: This was grouped as 'yes' or 'no' based on school attendance at the time of survey completion.

Chronic Conditions: Respondents were asked whether their child had the following chronic health conditions: arthritis, chronic back pain, rheumatism, osteoporosis, asthma, chronic bronchitis, emphysema, serious vision problems not correctable with glasses (e.g., cataracts, glaucoma, blindness), hearing impairment, epilepsy, psychological or nervous disorders, cognitive or mental disability, Attention Deficit Disorder/Attention Deficit-Hyperactivity Disorder, learning disability, heart disease, high blood pressure, stroke, thyroid problems, cancer, liver disease, stomach or intestinal problems, HIV/AIDS, hepatitis, tuberculosis or diabetes. The number of chronic conditions was summed and participants were placed into the following groups: '0', '1', '2' and '[greater than or equal to]3' chronic conditions.

Family factors

Family Structure: Parental structure in the home was grouped as follows: 'living with both biological parents', 'living with one biological parent' or 'living with no biological parents'. The number of people living within the household (excluding the respondent) was grouped as '<3', '3 or 4', '5 or 6' or '[greater than or equal to]7'.

Family Socio-economic Status: The parents'/guardians' highest level of education was grouped as '<high school', 'high school graduate' or 'any post-secondary education'.

Family Culture: Respondents were asked "Who helps your child in understanding their culture?", with check boxes provided for several people, including parents, grandparents, aunts/uncles and other relatives. Based on the number of relative groups selected, participants were placed into the following groups: '0 relatives', '1 relative', '2 relatives' or '[greater than or equal to]3 relatives'.

Community factors

Community Size: Based on the community of residence, participants were considered to live within a small (<300 people), a medium (300-1,499 people) or a large sized ([greater than or equal to]1,500 people) First Nations community.

Community Culture: The number of community members who help the child understand their culture was assessed by asking "Who helps your child understand their culture?", with the following list provided: school teachers, community elders, and other community members. Positive responses for each item were given 1 point and negative responses 0 points. Points were summed to create the following groups: '0', '1', '2' and '[greater than or equal to]3' community members.

Physical activity

Respondents were asked to report whether or not their child had participated in 20 different common physical activities over the previous 12 months, including activities that reflect First Nations culture and tradition (e.g., berry picking, hunting/trapping, fishing, canoeing). For each activity, they were asked to report on the frequency and the typical duration of participation. This information was used to estimate the typical weekly minutes of moderate-to-vigorous physical activity (MVPA). Because bowling and berry picking fall below the moderate intensity range (i.e., <4 times higher than resting energy expenditure), (14) these activities were removed before summing the activities to determine the average daily minutes of MVPA. Children were placed into two groups based on adherence to the MVPA guideline of 60 minutes per day: 'physically inactive' and 'physically active'. (15) Finally, to examine physical activity participation through a cultural lens, a 'yes' or 'no' group was created with regard to participation in at least one of the following traditional First Nations physical activities: berry picking, hunting/trapping, fishing, and canoeing/kayaking.

Statistical analysis

Analyses were conducted using IBM SPSS Complex Samples. All analyses took into account the multi-stage stratified design of the RHS by incorporating the design information into the models to adjust for the disproportionate sampling and cluster sampling. Initially, descriptive statistics were calculated for the study variables. Next, bivariate logistic regression analysis was used to determine whether each of the intrapersonal, family and community factor variables predicted each of the physical activity outcomes (e.g., accumulate [greater than or equal to]60 min/day of MVPA, participate in traditional physical activities). This was followed by multivariate logistic regression analysis. Three steps were used to determine the final multivariate model. In the first step, all of the intrapersonal factors were added to the model. These factors were only retained for the second step if they were significantly (p[less than or equal to]0.20) related to the physical activity outcomes. In the second step, the family factors were added to the model. The factors that were significantly (p[less than or equal to]0.20) related to the physical activity outcomes in step 2 were retained for step 3. In the third step, the community factors were added to the model and all factors that were significantly (p[less than or equal to]0.20) related to the physical activity outcomes were retained to create the final model. Because the analyses were exploratory, we selected a p[less than or equal to]0.20 to ensure that all potential factors would be included in the final multivariate model, after controlling for other variables in subsequent steps.

RESULTS

A description of the First Nations child population is provided in Table 1. The majority of First Nations children have no chronic health conditions (59%), attend school (99%), at least partially understand and use a First Nations language (56%), live with at least one of their biological parents (89%), and live in a community with 300-1,499 people (52%). Based on parent reports, 72% of First Nations children engage in an average of at least 60 minutes/day of MVPA and 54% engaged in at least one traditional First Nations physical activity in the previous year.

The associations between intrapersonal, family and community factors and participation in [greater than or equal to]60 minutes/day of MVPA are shown in Table 2. After controlling for the other variables in the multivariate model, the odds ratio (OR) of being physically active were higher in 9-11 year olds (OR=1.34), children living in households with more people (OR=1.38, OR=1.30 and OR=1.71 for 3-4, 5-6 and [greater than or equal to]7 people in household respectively), and children who had community members helping them understand their culture (OR=1.36, OR=1.97 and OR=3.01 for 1, 2 and [greater than or equal to] 3 community members respectively). None of the other intrapersonal, family or community factors was a significant independent predictor of engaging in an average of [greater than or equal to]60 minutes/day of MVPA.

Table 3 shows the associations between intrapersonal, family and community factors and participation in traditional First Nations physical activities (e.g., berry picking, hunting/trapping, fishing, canoeing/kayaking). The significant independent predictors among the intrapersonal factors were school attendance (OR=2.27) and understand and use a First Nations language most often in daily life (OR=1.65). As for the family factors, the multivariate analyses revealed that children with a parent with at least some post-secondary education had an increased odds (OR=1.33) of participating in a traditional First Nations physical activity in the year prior to the survey. At the community level, OR increased for children from smaller communities (OR=1.49 for communities with 300-1,499 people, OR=2.30 for communities with <300 people) and for children who had more community members help them understand their culture (OR=2.14 for 2 community members, OR=1.83 for [greater than or equal to]3 community members).

DISCUSSION

Results from the RHS suggest that when averaged across all days of the year, 72% of First Nations children accumulate at least 60 minutes/day of MVPA. This statistic is encouraging given the many health benefits associated with physical activity. However, this should not be interpreted as meaning that the majority of First Nations children meet Canadian (15) or global (16) physical activity guidelines, both of which recommend that school-aged children accumulate 60 minutes of MVPA on a daily basis, as accumulating 60 minutes on a daily basis is not the same as averaging 60 minutes over several days. The importance of this distinction is highlighted in findings from the 2007-2009 Canadian Health Measures Survey, which measured MVPA objectively using accelerometers. The findings from that survey indicate that the average daily MVPA in the mainstream 6-10 year old population is 62 minutes/day, but that only 11% of these children accumulate 60 minutes of MVPA on a daily basis and meet physical activity guidelines. (1) Similarly, Lemstra and colleagues found that only 6% of a small sample of 10-12 year old Saskatoon Tribal Council First Nations on-reserve children met physical activity guidelines. (3)

Apart from age, with children aged 9-11 years being more likely to be active than 6-8 year olds, no other intrapersonal factors were associated with MVPA in First Nations children. Approximately 10% of First Nations children had more than one chronic condition and 1% did not attend school; the smaller proportion of these risk factors in the study may in part explain why they were not significant correlates of MVPA or traditional physical activities.

Consistent with previous reviews that have included social and environmental factors, (17) many of the family-level and community-level factors examined in our analyses of First Nations children were not consistently independently associated with MVPA or traditional physical activities. Cultural factors at each of these levels were most consistently associated with MVPA and traditional First Nations physical activities; both factors reflected the number of people (i.e., family and community members) who help the child understand their culture. In general, children with more cultural support were more likely to be active and children with less cultural support were less likely to be active. This finding is compatible with related research showing that culture is important in understanding health and health behaviours in First Nations youth and adults. (5,18) This finding warrants further investigation given that parent/guardian perceptions of the importance of traditional cultural events in their child's life was not independently associated with MVPA or traditional physical activities.

Physical activity is often perceived as good medicine among Aboriginal peoples, and traditional activities are considered especially relevant in this regard. (6) To this end, our findings suggest that 54% of First Nations children engaged in a traditional First Nations physical activity in the year prior to the survey. Two of the five factors that were significant independent predictors of involvement in traditional physical activities were about culture. Specifically, knowledge of a First Nations language and high levels of community cultural support emerged as being the relevant predictors of participation in traditional physical activity. It may be that traditional physical activities are pursued as a way to preserve and promote traditional cultural practices in general. (6)

The current analysis provides new insight into physical activity correlates among 6-11 year olds living in First Nations on-reserve communities and has applications for future research and for designing interventions. By focusing on First Nations children, this analysis conforms to recommendations that research of Aboriginal health and health behaviours focus on specific Aboriginal groups, rather than grouping First Nations, Metis and Inuit peoples together. (19) The findings also confirm the relevance of examining correlates of physical activity using an ecological lens. (17) This ecological view provides insight into the design of interventions for promoting an active lifestyle among First Nations children. Specifically, the findings imply that physical activity interventions are more likely to be successful if they include components that address intrapersonal, interpersonal and community factors.

Some limitations should be acknowledged. Parent-reported physical activity is known to be over-reported and only modestly correlated to physical activity measured objectively using accelerometers and heart rate monitoring. (20) Thus, the proportion of First Nations children meeting the [greater than or equal to]60 minutes/day MVPA target was likely lower than what was reported here, and the association between the 12 independent variables and the 2 physical activity outcomes were likely underestimated. Specificity about the types of traditional activities performed was also lost in this analysis because response options for berry picking, hunting/trapping, fishing, and canoeing/kayaking were grouped. Given the important differences in energy expenditure required to engage in these activities, (21,22) future research should consider distinguishing between activity types. In addition, traditional activities such as drumming and traditional dancing were not measured within the context of physical activity. Finally, analyses were constrained by the limitations inherent in the secondary analysis of surveillance data.

In conclusion, correlates of physical activity among First Nations children residing in First Nations communities in Canada were examined using an ecological analysis. Participation in MVPA and traditional First Nations physical activities was affected by multiple intrapersonal, interpersonal and environmental factors. Having multiple community members helping the child understand their culture was a particularly strong correlate of both MVPA and traditional physical activities.

REFERENCES

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(12.) Stokols D. Establishing and maintaining healthy environments. Toward a social ecology of health promotion. Am Psychol 1992;47(1):6-22.

(13.) The First Nations Information Governance Centre. First Nations Regional Health Survey (RHS) Phase 2 (2008/10) National Report for Adults, Youth and Children Living in First Nations Communities. Ottawa, ON: The First Nations Information Governance Centre, 2012.

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(16.) World Health Organization. Global Recommendations on Physical Activity for Health. Geneva, Switzerland: World Health Organization, 2010. Available at: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/in dex.html (Accessed November 1, 2014).

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(18.) Wilson K, Rosenberg MW. Exploring the determinants of health for First Nations peoples in Canada: Can existing frameworks accommodate traditional activities? Soc Sci Med2002;55(11):2017-31.

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Received: May 1, 2014 Accepted: September 15, 2014

Ian Janssen, PhD, [1,2] Lucie Levesque, PhD, [1] Fei Xu, PhD [3] and the First Nations Information Governance Centre [3]

Author Affiliations

[1.] School of Kinesiology and Health Studies, Queen's University, Kingston, ON

[2.] Department of Public Health Sciences, Queen's University, Kingston, ON

[3.] First Nations Information Governance Centre, Ottawa, ON Correspondence: Ian Janssen, School of Kinesiology and Health Studies, Queen's University, Kingston, ON K7L 3N6, Tel: 613-533-6000, ext.78631,

E-mail: [email protected]

Source of support: Funding was provided by the First Nations Information Governance Centre.

Conflict of Interest: Ian Janssen and Lucie Levesque received consulting fees from the First Nations Information Governance Centre. Fei Xu is employed by the First Nations Information Governance Centre.

Table 1. Description of 6-11 year old child participants of
the 2008/10 First Nations Regional Health Survey

Variable              N     % of total

Age (years)
  6-8                1550      47.5
  9-11               1634      52.5
Gender
  Female             1625      50.8
  Male               1556      49.2
Physical activity
  [greater than      2087      71.8
    or equal to]
    60 min/day of
    moderate-to-
    vigorous
    activity
  Participate in     1734      53.6
    traditional
    First Nations
    activities
Number of chronic
    conditions
  0                  2175      59.2
  1                   679      20.4
  2                   203       6.5
  [greater than       124       3.9
    or equal to] 3

Attend school
  No                   24       0.8
  Yes                3145      99.2
Knowledge of First
    Nations
    language
  Do not             1383      43.5
    understand
    or speak
  Understand but     1017      33.3
    do not use
    most often
  Understand and      690      23.2
    use most
    often in
    daily life
Parental structure
  Live with no        325      11.1
    biological
    parents
  Live with 1        1386      43.4
    biological
    parent
  Live with both     1473      45.5
    biological
    parents
Community size
  < 300 people        436       6.2
  300-1,499 people   1737      51.7
  [greater than      1011      42.2
    or equal to]
    1,500 people

Table 2. Associations between intrapersonal, family and community
factors and participation in 60 min/day of moderate/to/vigorous
physical activity in 6/11 year old child participants of the
2008/10 First Nations Regional Health Survey

Variable                %      Bivariate            Multivariate OR
                               OR (95% CI) *        (95% CI)
                                                    ([dagger])

Intrapersonal
    factors
  Age (years)
    6-8                 68.7   1 l(referent)        1 (referent)
    9-11                74.6   1.34 (1.10-1.63) #   1.34 (1.11-1.62) #
  Gender
    Female              70.3   1 (referent)         1 (referent)
    Male                73.3   1.15 (1.15-1.41)     1.17 (0.96-1.43)
  Number of
      chronic
      conditions
    0                   71.6   1 (referent)         N/A
    1                   72.8   1.06 (0.83-1.37)
    2                   71.6   1.00 (0.59-1.69)
    [greater            70.7   0.96 (0.61-1.52)
      than or
      equal to] 3
  Attend school
    No                  65.2   1 (referent)         N/A
    Yes                 71.8   1.36 (0.51-3.63)
  Knowledge
      of First
      Nations
      language
    Do not              68.9   1 (referent)         N/A
      understand
      or speak
    Understand          71.9   1.15 (0.88-1.51)
      and use most
      often in
      daily life
    Understand          74.8   1.34 (1.04-1.72) #
      but do not
      use most
      often
  Importance of
      First Nations
      culture
    Not important       75.3   1 (referent)         N/A
    Not very            67.7   0.69 (0.35-1.34)
      important
    Somewhat            69.7   0.76 (0.44-1.29)
      important
    Very important      72.8   0.88 (0.52-1.48)
Family factors
  Parental
      structure
    Live with no        64.4   1 (referent)         N/A
      biological
      parents
    Live with 1         73.7   1.41 (0.99-1.99) #
      biological
      parent
    Live with both      71.8   1.55 (1.06-2.27) #
      biological
      parents
  # People in
      household
      (excluding
      child)
    < 3                 62.2   1 (referent)         1 (referent)
    3-4                 64.1   1.26 (0.92-1.69)     1.38 (1.01-1.89) #
    5-6                 68.0   1.25 (0.91-1.73)     1.30 (0.94-1.81)
    [greater            72.5   1.60 (1.02-2.50) #   1.71 (1.12-2.63) #
      than or
      equal to] 7
  Parental education
    < High school       66.3   1 (referent)         1 (referent)
      graduate
    High school         68.2   1.25 (0.96-1.64) #   1.27 (0.97-1.67)
      graduate
    [greater than       64.2   0.92 (0.72-1.16)     0.88 (0.69-1.13)
      or equal to]
      Some post-
      secondary
  # Relatives who
      help child
      understand
      culture
    0                   74.8   1 (referent)
    1                   64.1   0.60 (0.41-0.90) #
    2                   70.2   0.80 (0.52-1.23)
    [graeter than       76.2   1.08 0.73-1.60)
      or equal to] 3
Community Factors
  Community size
    [greater than       69.9   1 (referent)
      or equal to]
      1,500 people
    300-1,499 people    73.2   1.18 (0.92-1.50)
    < 300 people        72.7   1.15 (0.78-1.68)     N/A
  # Community members
      who help child
      understand
      culture
    0                   66.1   1 (referent)         1 (referent)
    1                   71.4   1.26 (0.99-1.60)     1.36 (1.08-1.72) #
    2                   77.1   1.70 (1.20-2.41) #   1.97 (1.40-2.77) #
    [greater than       82.8   2.43 (1.64-3.59) #   3.01 (2.04-4.45) #
      or equal to] 3

* Bivariate odds ratio (95% confidence interval).

([dagger]) Multivariate odds ratio (95% confidence interval)
adjusted for other intrapersonal, family and community factors.

N/A = not applicable as variable not included in final
multivariate model.

Bold numbers indicate statistically significant odds ratios (p <
0.05).

Note: The statistically significant odds ratios (p < 0.05) are
indicated with #.

Table 3. Associations between intrapersonal, family and community
factors and participation in traditional First Nations physical
activities in 6/11 year old child participants of the 2008/10
First Nations Regional Health Survey

Variable                  %         Bivariate          Multivariate
                                  OR (95% CI) *        OR (95% CI)
                                                        ([dagger])

Intrapersonal factors
  Age (years)
    6-8                  53.1   1 (referent)        1 (referent)
    9-11                 54.1   1.04 (0.87-1.24)    1.03 (0.85-1.24)
  Gender
    Female               55.7   1 (referent)        1 (referent)
    Male                 51.5   0.84 (0.70-1.02)    0.86 (0.70-1.05)
  Number of
      chronic
      conditions
    0                    51.8   1 (referent)        N/A
    1                    57.2   1.24 (0.98-1.57)
    2                    58.6   1.30 (0.83-2.02)
    [greater than        60.3   1.41 (0.93-2.14)
      or equal to] 3
  Attend school
    No                   24.5   1 (referent)        1 (referent)
    Yes                  53.8   3.60 (1.16-8.00) #  2.27 (1.07-4.79)
  Knowledge of
      First Nations
      language
    Do not               46.8   1 (referent)        1 (referent)
      understand
      or speak
    Understand and       60.6   1.75 (1.38-2.22) #  1.65 (1.28-2.13)
      use most often
      in daily life
    Understand but       55.7   1.43 (1.11-1.84) #  1.30 (0.99-1.71)
      do not use
      most often
  Importance of First
      Nations culture
    Not important        51.3   1 (referent)        N/A
    Not very important   46.8   0.83 (0.49-1.42)
    Somewhat important   50.5   0.97 (0.60-1.56)
    Very important       57.3   1.27 (0.81-1.99)
Family factors
  Parental structure
    Live with no         48.4   1 (referent)        N/A
      biological
      parents
    Live with 1          54.8   1.29 (0.93-1.80)
      biological
      parent
    Live with both       53.8   1.24 (0.91-1.69)
      biological
      parents
  # People in
      household
      (excluding
       child)
    < 3                  39.9   1 (referent)        N/A
    3-4                  42.2   1.05 (0.84-1.31)
    5-6                  41.2   0.94 (0.74-1.21)
    [greater than        37.9   1.19 (0.86-1.65)
      or equal to] 7
  Parental education
    < High school        36.0   1 (referent)        1 (referent)
      graduate
    High school          39.2   1.02 (0.80-1.30)    0.90 (0.70-1.16)
      graduate
    [greater than        50.3   1.43 (1.13-1.80) #  1.33 (1.05-1.68) #
      or equal to]
      Some post-
      secondary
  # Relatives who
      help child
      understand
      culture
    0                    42.4   1 (referent)        N/A
    1                    48.3   1.27 (0.88-1.81)
    2                    53.3   1.55 (1.08-2.23) #
    [greater than        59.5   2.00 (1.37-2.91) #
      or equal to] 3
Community factors
  Community size
    [greater than        47.7   1 (referent)        1 (referent)
      or equal to]
      1,500 people
    300-1,499 people     56.9   1.45 (1.15-1.83) #  1.49 (1.17-1.89) #
    < 300 people         66.6   2.19 (1.63-2.93) #  2.30 (1.67-3.17) #
  # Community members
      who help child
      understand
      culture
    0                    45.8   1 (referent)        1 (referent)
    1                    52.4   1.30 (1.02-1.65) #  1.17 (0.92-1.49)
    2                    67.4   2.45 (1.79-3.33) #  2.14 (1.53-2.98) #
    [greater than        63.4   2.05 (1.38-3.03) #  1.83 (1.22-2.75) #
      or equal to] 3

* Bivariate odds ratio (95% confidence interval).

([dagger]) Multivariate odds ratio (95% confidence interval)
adjusted for other intrapersonal, family and community factors.

N/A = not applicable as variable not included in final
multivariate model.

Bold numbers indicate statistically significant odds ratios (p <
0.05).

Note: The statistically significant odds ratios (p < 0.05) are
indicated with #.